N.Y. Comp. Codes R. & Regs. tit. 9 § 210.6

Current through Register Vol. 46, No. 25, June 18, 2024

Section 210.6 - Claims Process

(a)

(1) An eligible volunteer firefighter or their beneficiary(ies) shall file a claim with the benefit provider within 120 days after the diagnosis of a covered cancer, the death of the eligible volunteer firefighter, or commencement of a covered total disability. Failure to file a claim within such time shall not invalidate or reduce any claim if it shall be shown not to have been reasonably possible to file such claim and that a claim was filed as soon as reasonably possible. A claim shall be filed by submitting a claim form(s) as may be required by the benefit provider to the benefit provider. The claim form must be signed by the eligible volunteer firefighter or their beneficiary(ies) and sworn to under penalty of perjury as true, correct and complete.

(2) The benefit provider shall have the right and opportunity to examine the person of the eligible volunteer firefighter when and as often as the benefit provider may reasonably require during the pendency of claim and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law.

(b) The benefit provider shall review the claim and determine if the claim will be paid within thirty (30) days of receipt of the claim. However, if the benefit provider requires additional information from the claimant to make a determination, the benefit provider shall provide written notice to the claimant within such thirty (30) days requesting the information. The claimant shall be afforded at least forty-five (45) days from receipt of the request to furnish the information. The thirty (30) days in which the benefit provider shall make a determination on the claim shall be tolled and shall resume as of the date the claimant furnishes the information to the benefit provider or the end of the forty-five (45) day period afforded to the claimant to provide such information.

(c) If the claim is approved, the benefit provider shall mail or deliver written notification to the claimant and the fire district, department or company within five (5) business days of the approval. The benefit provider shall pay benefits within thirty (30) days of mailing or delivering such notification.

(d) If the claim is denied, the benefit provider shall mail or deliver written notification to the claimant and the fire district, department or company within five (5) business days of the denial. If the benefit provider making the denial is an insurance company, then the written denial notification shall include a statement that the claimant may file a complaint with the New York State Department of Financial Services and provide the Department's website address, mailing address, and telephone number. Any denial notification by a benefit provider shall include the reasons for such denial. The only permissible reason(s) for denial of a claim shall be the following:

(1) the volunteer firefighter does not have 5 or more years of service as interior firefighter; or

(2) the volunteer firefighter did not successfully complete a physical examination, prior to the commencement of duties as an interior firefighter, which examination failed to reveal any evidence of cancer; or

(3) the volunteer firefighter has not passed 5 yearly fit tests; or

(4) the volunteer firefighter ceased to be an active volunteer firefighter for more than sixty (60) months prior to the submission of the claim for benefits; or

(5) The volunteer firefighter is receiving or has already received benefits as a paid firefighter under General Municipal Law Article 10; or

(6) The diagnosis of cancer is not for a type covered by this Part; or

(7) the volunteer firefighter does not have a total disability as referenced in General Municipal Law section 205-c c(2)(c).

(e) Upon receipt of the denial of the claim, the claimant shall have sixty (60) days to appeal the denial pursuant to section 210.7 of this Part.

N.Y. Comp. Codes R. & Regs. Tit. 9 § 210.6

Adopted New York State Register October 17, 2018/Volume XL, Issue 40, eff. 10/17/2018